1MSc Student of Midwifery, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

2Assistant Professor of Midwifery, Evidence-Based Care Research Center, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran

3Professor of Quranic Sciences, Department of Cultural Affairs, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

4Associate Professor of Statistics, Department of Biostatistics and Epidemiology, School of Public Health , Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Background &aim: Stability and survival of marital life depends on the love and positive feelings towards spouse in married couples. Sexual assertiveness is considered as a person's ability to have intercourse to meet his/her sexual needs and promote sexual relationships with the spouse. The more couples are aware of each other's sexual needs and can satisfy those needs, the more desirably their emotional bond are developed. This study was conducted to determine the relationship between sexual assertiveness and positive feelings towards spouse in married women.Methods: This correlational study was conducted in 2016 on 60 women visiting Imam Reza Medical Center in Mashhad, Iran. The subjects who were selected through convenience sampling were married and involved in a heterosexual marriage for a minimum of one year. Data was collected using Halbert Index of Sexual Assertiveness and Positive Feelings Questionnaire. To analyze the data, Pearson correlation coefficient, multivariate regression, Mann-Whitney U test, and Chi-squared test were run in SPSS, version 16.Results: Higher sexual assertiveness scores were associated with more positive feelings towards spouse. The multivariate regression analysis reflected a significant positive correlation between sexual assertiveness and positive feeling toward spouse (r=0.5, P<0.01).Conclusion: Sexual assertiveness and positive feelings towards spouse are significantly associated, and they affect couples’ emotional and sexual relationship. Considering mutual agreement and sexual rights among couple, providing sexual care and consultancy services are recommended for married women to improve their sexual assertiveness and positive feelings towards their husband.

Human motives for entering marital life are overcoming loneliness, gaining independence from parents, satisfying emotional and sexual needs, and having off springs. Family is the most suitable place to meet human needs, and it is the best place for procuring security and mental relaxation (1).

Among the most important purposes of marriage in Islam, with great influences on our culture, are couple’s peace of mind and heart in the context of establishing deep emotional bonds. The holy Quran pointed out to this fact in many verses, including: “It is He who created you from a single person, and made from it its mate, that he may find comfort with her” (The Elevations, verse 189) and “And of His signs is that He created for you mates from among yourselves, so that you may find tranquility in them; and He planted love and compassion between you” (The Romans, verse 21) (2, 3).

Emotional needs can present in both mature and immature forms. Mature emotions make one feel connected not dependent, give an insight not prejudice, sustain individuality in unity, and feature collaboration not competition. On the other hand, immature emotions are extreme loving that lead to monopoly, domination of feelings over logic, conditional love, and loss of individuality and personality, which in turn, cause development of marital issues and misunderstanding. Maturity instigates positive emotions to flow, that is, friendship, marital relations, understanding, honesty, trust, pleasure, and sexual pleasure are experienced in marital life. The stability and survival of marriage relationship require love and positive feelings towards spouse in married couples. This feeling can eliminate tension between couples and diminish selfishness (1).

Couples experiencing a deep, logical, and intimate emotional relationship are successful people with high self-esteem, positive thoughts, and a sense of joy and happiness. Conversely, couples lacking proper emotional relationships feel lonely and irritable, have very low levels of social adaptability, experience failure and hopelessness, and always bear negative emotions such as misfortune (3, 4). There is a direct relationship between couples’ intimacy and emotional attachment and their sexual balance and satisfaction (5). The more couples are aware of each other's sexual needs and are better capable of satisfying those needs, their emotional bonds become deeper (6, 7).

Various studies indicated that lack of sexual satisfaction is the cause of a variety of mental disorders, which is especially true in women. Emotional and psychological issues are highly important in women’s sexual relations, and if left unattended, it would be very difficult to satisfy the woman physically (3). In Iran, many women have unmet sexual desires, and about 50-60% of divorces and 40% of infidelities are due to this same reason (8-10).

The term assertiveness or sexual assertiveness is defined as psychosocial feelings towards expressing emotions in marital relationship (11). According to Elsenbruch (2003) report, 51% of men and 48% of married women stated that men first initiate sexual behaviors, while only 12% of women and 16% of men considered women as initiators of sexual relationship (12). In many societies, women have low self-esteem and difficulty in self-realization, and it is hard for them to express their sexual needs or maintain their individual autonomy in marriage relationship (13). In several studies performed in Iran, women asserted that their husbands did not understand their emotional and sexual needs, and their sexual desires were not fulfilled in their marital relationship (6).

Based on the above-mentioned findings, there is limited information regarding sexual issues, attitudes, and beliefs in the current Iranian community (10). Further, low-quality emotional and sexual relations might be due to lack of mutual understanding of emotional and sexual needs (14). Considering the scarcity of studies on sexual assertiveness and its relationship with positive feelings towards spouse, we sought to determine the relationship between sexual assertiveness and positive feelings of married women towards their husbands.

Materials and Methods

This correlational study was conducted in 2016 on 60 women visiting Imam Reza (AS) Medical Center in Mashhad, Iran. After obtaining approval of the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran, sampling was performed. The subjects were selected using convenience sampling method. The standard sample size was estimated to be 60 based on mean differences and sample size formula with the confidence interval of 95% (α=0.05) and test power of 90%, and based on the results of Hassanabadi et al. in 2011 (15).

The researcher approached women who visited the center for health care services, discussed the research design, methodology, how to complete the questionnaires, and assured them of confidentiality of their personal data. Then, if they signed the written informed consent to participate in the study, the sample selection checklist was completed through interview and based on the inclusion and exclusion criteria. The inclusion criteria were having basic education, being married, living with the husband, husband's monogamy, first marriage of the couples, being married for at least a year, and having sexual intercourse over the past month. The exclusion criteria comprised of pregnancy, drug addiction, medical or psychological diseases, hormone therapy, incidence of stressful events during the last six months for the couple, and treatment for sexual dysfunction.

The study participants (after teaching them on how to answer the questionnaires) completed the demographic form, as well as Halbert Index of Sexual Assertiveness and Positive Feelings Questionnaire.

Halbert index of sexual assertiveness

This questionnaire contains 25 items rated using a 5-point Likert scale ranging from "Always (0)" to "Never (4)". The questions 3, 4, 5, 7, 12, 15, 16, 17, 18, 21, 22 and 23 are reverse scored (Always=4 and Never=0). The possible test scores range from 0 to 100 with higher scores indicating higher sexual assertiveness, while lower scores showed lower sexual assertiveness. The sexual assertiveness questionnaire was validated in a study by Hulbert David Farley (1991) (16). In Iran, Bay (2008) confirmed its content validity and internal consistency (α=0.91) (13). In the study by Halbert, the Cronbach's alpha coefficient was calculated at α=0.86. In its implementation by Shafiee (2006), the Cronbach's alpha coefficient was obtained to be α=0.92 (17). Reliability of this scale was computed in the current study to be α=0.84.

Positive Feelings Questionnaire

This questionnaire consists of 17 items measuring positive feelings towards spouse and was developed by O’Leary et al. in 1975 at the couple therapy clinic of the State University of New York, the US. This questionnaire was designed in two parts. In the first part, the subjects are asked to determine their feelings toward their spouse on a scale of 1 (strongly negative) to 7 (strongly positive). In the second part, which includes nine items, the participants are asked to select a phrase that best describes their overall feelings towards their spouse with numbers 1-7.

The total questionnaire score is simply computed by adding question scores. The possible scores range between 94 and 114, with higher scores indicating more positive feelings. The Positive Feelings Questionnaire was validated by O’Leary (1981) (18). Mazaheri and Poor-Eatemadi (2001) confirmed the reliability of the questionnaire for application in Iran (1). This questionnaire is sensitive to changes occurring during marital treatment (Sanaei, 2000). Using the test-retest method, the questionnaire’s reliability was computed at α=0.93 by Toknizi and O’Leary (1981). This questionnaire was translated into Persian, and then back-translated to establish its validity; the computed reliability for the Persian version of the questionnaire was α=0.89 (Mazaheri, 2001). We calculated the reliability of this scale in the current study at α=0.93.

To analyze the data, descriptive statistics (i.e., mean, standard deviation, range, and distributions), Spearman correlation coefficient, Mann-Whitney U test, Chi-squared test, and multivariate regression model were used in SPSS, version 16. P-value less than 0.05 was considered statistically significant.

Ethical considerations

In this study, all the 26 moral codes of human subjects protection related to the research topic (paragraphs 1-3, 5-12, 17, 20) were observed. The ethical and scientific contents of this study were approved by Mashhad University of Medical Sciences (code of research ethics: IR.MUMS.REC.1395.284).

Results

Data analysis showed that mean age of the participants was 30.51±7.97 years (age range: 14-50 years). The mean age of their husbands was 35.14±8.27 years (age range: 24-60 years). Furthermore, 36 (60%) of the participants had a separate bedroom from the rest of the family, 46 participants (76.7%) were housewives, and 47 (66.6%) of the husbands were self-employed (Table 1).

Mean score of positive feelings towards the spouse was 100.28±15.74, and the mean of sexual assertiveness was 53.68±16.68.

Multivariate regression analysis was performed to determine the relationship between positive feelings towards spouse andTable 1. Frequency distribution of some demographic characteristics of the study subjects

No.(%)

Variable

Have a separate bedroom

36(60.0)

Yes

24(40.0)

No

Occupation

46(76.7)

Housewife

14(23.3)

Employed

Husband’s occupation

5(8.3)

Unemployed

8(13.4)

Employee

47(78.3)

Self-employed

sexual assertiveness, having a separated bedroom, participant’s occupation, and husband’s occupation. The multivariate correlation coef-ficient of the independent and dependent variables of positive feelings towards spouse was 0.64 and the square root of multivariate correlation coefficient was 0.41. Therefore, the four variables of sexual assertiveness, having a separate bedroom, participant’s occupation, and husband’s occupation could explain 41% of variance in positive feelings towards spouse.

Having a separate bedroom, as well as participant and her husband’s occupation did not have any significant regression coefficients. Accordingly, they play a marginal role in explaining the variance in positive feelings towards spouse and most of the variance was due to the sexual assertiveness variable (regression coefficient: 0.52; Table 2).

This study was conducted to explore the relationship between sexual assertiveness and positive feelings towards spouse. Based on our findings, there is a significant positive relationship between sexual assertiveness and positive feelings towards spouse. Basak-Neghad et al. (2013) conducted a study entitled as "The relationship between personality traits and spiritual intelligence with positive feelings toward spouse". They found the strongest predictors of positive feeling towards spouse to be spiritual intelligence, agreeableness in men and extraversion, conscientiousness, agreeableness in women (19).

Haidari et al. (2005) carried out a correlational study entitled as "The relationship between socializing beliefs with positive feelings toward spouse" on a sample of 121 volunteer couples. Their findings suggested that irrational beliefs in men and women could undermine positive feelings towards spouse (20). The observed rise in positive feelings towards spouse in these studies could be due to influence of psychological traits, such as personality traits, spiritual intelligence, and socializing beliefs, on positive feelings towards spouse. Indeed, couples who can manage their marital conflicts through using positive approaches and preventing negative interactions create an atmosphere in which there are more opportunities for self-revelation and agreement on family issues, which is an important approach to enhancing positive feelings towards spouse.

Asadi et al. (2013) performed a study entitled as "The relationship between marital distraction, dysfunctional sexual beliefs, and sexual assertiveness among married women". They found an inverse relationship between sexual assertiveness and total score of dysfunctional sexual beliefs and marital distraction (21).

Table 2. Multivariate regression analysis of the relationship of positive feelings towards spouse with sexual assertiveness, having a separate bedroom, as well as the participants and their husbands’ occupation

Significance

T-value

Standard regression coefficient

Standard deviation

Regression coefficient

Variable

0.000

4.41

0.52

0.11

0.49

Sexual assertiveness

0.367

-0.91

-0.10

3.73

-3.39

Having a separate bedroom

0.185

-1.34

-0.14

1.45

-1.95

Woman’s occupation

0.175

1.37

0.14

1.56

2.14

Husband’s occupation

and sexual desire in married female students of Khwarizmi University". They revealed a significant direct relationship between sexual assertiveness and sexual desire, and between sexual assertiveness and secure attachment, but a significant reverse relationship between sexual desire and avoidant attachment, sexual desire and ambivalent attachment, and sexual assertiveness and avoidant attachment style (22). Sexual issues are the cause of a wide range of psychological disorders, especially in women. Emotional and psychological parameters play an important role in women's sexual relationship, and if they are not attended to, it would be difficult to satisfy the woman physically. Traditional stereotypes have some impact on this matter. These stereotypes include women should submit to sexual relationship with their husbands (5). If couples are satisfied with their sexual relationship and have mutual satisfaction, they will enjoy physical and mental health in addition to lesser issues and conflicts in the household, stronger adherence to the sacred vows of marriage, and no ethical and sexual deviations and infidelities (23).

One of the primary purposes of marriage is fulfilling sexual needs. Positive feelings between couples have a direct relationship with sexual balance and satisfaction, and the main cause of connectedness conflicts is sexual disturbance (5). The higher couples’ understanding is from each other’s sexual needs, and the more desirably they observe mutual rights and satisfy mutual needs, the stronger and deeper their emotional bonds become (5, 24). Sexual assertiveness is considered as a person's ability to have intercourse to meet sexual needs and control the conduct of sexual behaviors with the spouse (25); this concept is directly associated with positive feelings towards spouse. Sexual relationship along with acknowledging marital rights and duties can help with fostering this positive feeling and increasing a person’s sexual assertiveness through strengthening this positive feeling, which in turn, leads to having a pleasant and effective sexual relationship.

The limitation of this study includes the cultural taboo of talking about sexual issues that prevents normal behavior, which was partially controlled. The strength of this study was investigation of the relationship between sexual assertiveness and positive feelings towards spouse despite taboos and cultural barriers and expanding the subject related to emotional and sexual factors.

Conclusion

Sexual assertiveness has a significant relationship with positive feelings towards spouse and affects emotional and sexual relationship of couples. Further, considering the sexual rights and agreement between spouses, it is recommended to implement educational courses on sexual assertiveness and positive feelings towards spouse for married women visiting centers for sexual care and consultation.

Acknowledgements

This article was derived from a Master's thesis project (code: 950500), approved by Mashhad University of Medical Sciences, Mashhad, Iran, and funded by the Research Committee. Hereby, we wish to thank the Deputy of Research, staff, and midwives of Imam Reza Medical Center.

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